Healthcare Provider Details

I. General information

NPI: 1982175485
Provider Name (Legal Business Name): MARY G WYNNE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2018
Last Update Date: 12/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WOODS RD
VALHALLA NY
10595-1530
US

IV. Provider business mailing address

314 W WASHINGTON AVE
PEARL RIVER NY
10965-2154
US

V. Phone/Fax

Practice location:
  • Phone: 914-493-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number331679
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: